1.

A 22-year-old man is brought to the emergency department 25 minutes after an episode of violent jerky movements of his
arms and legs. He has no recollection of the episode. The episode lasted for 3

EMG

EEG

Lumbar puncture

2. A 23-year-old man comes to the emergency department for 2 days of episodic headaches. The pain is most intense on his
left forehead and eye. He had similar symptoms last summer. He has been taking indomethacin every 6 hours for the last 24
hours but has not had any relief. He has smoked 1 pack of cigarettes daily for the past 5 years. He works as an accountant and
describes his work as very stressful. He appears restless. Physical examination shows drooping of the left eyelid, tearing of the
left eye, and rhinorrhea. The left pupil is 2 mm and the right pupil is 4 mm. There is localized tenderness along the right
supraspinatus muscle. The remainder of the examination shows no abnormalities. Which of the following is the most likely
diagnosis?

Subarachnoid hemmorhage

Medication overuse headache

Cluster headache

Migraine headache

3. Which one of these abnormalities on the neurologic exam would be unusual in a patient with mild AD?

Problems drawing a clock

Impaired sense of smell

Hyperreflexia with positive Babinski signs

Impaired short-term memory

4. A 9-year-old boy is brought to the physician by his mother to establish care after moving to a new city. He lives at home with
his mother and older brother. He was having trouble in school until he was started on ethosuximide by a previous physician; he
is now performing well in school. This patient is undergoing treatment for a condition that most likely presented with which of
the following symptoms?

Regression of verbal skills and stereotyped hand-wringing

Episodic jerky movements of the arm and impaired consciousness

Frequent episodes of blank staring and eye fluttering

Recurrent motor tics and involuntary obscene speech

5. An 8-year-old boy is brought to the emergency department 3 hours after having a 2-minute episode of violent, jerky
movements of his right arm at school. He was sweating profusely during the episode and did not lose consciousness. He
remembers having felt a chill down his spine before the episode. Following the episode, he experienced weakness in the right
arm and was not able to lift it above his head for 2 hours. Three weeks ago, he had a sore throat that resolved with over-the-
counter medication. He was born at term and his mother remembers him having an episode of jerky movements when he had a
high-grade fever as a toddler. There is no family history of serious illness, although his father passed away in a motor vehicle
accident approximately 1 year ago. His temperature is 37.0
 Sydenham chorea

Sporadic transient tic disorder

Hemiplegic migraine

Focal seizure

6. A 33-year-old woman is noted to have daily severe headaches. Her physi- cian prescribed botulinum toxin injections, which
have been highly effec- tive. Which of the following types of headaches is most likely to be present?

Migraine vascular headache

Cluster vascular headache

Cervical muscle spasm

Tension headache

7. A previously healthy 42-year-old woman comes to the physician because of a 7-month history of diffuse weakness. There is
no cervical or axillary lymphadenopathy. Cardiopulmonary and abdominal examination shows no abnormalities. A lateral x-ray
of the chest shows an anterior mediastinal mass. Further evaluation of this patient is most likely to show which of the
following?

Acetylcholine receptor antibodies

Smoking history of 30 pack years

History of fever, night sweats, and weight loss

Increased urinary catecholamines

8. A 52-year-old man comes to the physician because of increasing weakness of his arms and legs over the past year. He has
also had difficulty speaking for the past 5 months. He underwent a partial gastrectomy for gastric cancer 10 years ago. His
temperature is 37.1

Multiple sclerosis

Myasthenia gravis

Amyotrophic lateral sclerosis

Ischemic Stroke

9. A 35-year-old woman comes to the physician because of a 1-month history of double vision, difficulty climbing stairs, and
weakness when trying to brush her hair. She reports that these symptoms are worse after she exercises and disappear after she
rests for a few hours. Physical examination shows drooping of her right upper eyelid that worsens when the patient is asked to
gaze at the ceiling for 2 minutes. There is diminished motor strength in the upper extremities. The remainder of the examination
shows no abnormalities. Which of the following is the most likely diagnosis?

Myasthenia gravis

Amyotrophic lateral sclerosis

Amyotrophic lateral sclerosis

10. A 68-year-old man comes to the physician because of a 3-month history of frequent falls and difficulty swallowing. He used
to go for long walks with his wife but stopped because he could not lift his right leg properly. He has no history of serious illness
and takes no medications. Muscle strength is 2/5 on extension of the right knee and flexion of the right hip. Patellar and ankle
reflexes are 1+ on the right leg and 3+ on the left leg. Sensation to pinprick, light touch, and vibration is intact. Cranial nerve
examination shows an exaggerated gag reflex and fasciculations of the tongue. Mental status examination shows a labile affect
and monotonous nasal speech. Results of screening laboratory studies, including a complete blood count, serum electrolyte
concentrations, and creatine kinase, are within the reference ranges. Needle electromyography discloses spontaneous
fasciculation potentials in multiple muscles. Nerve conduction studies are normal. This patient is at greatest risk for which of
the following complications?

Ascending paralysis

Myasthenic crisis

Internuclear ophthalmoplegia

Diaphragmatic dysfunction

11. A 52-year-old man comes to the physician because of increasing weakness of his arms and legs over the past year. He has
also had difficulty speaking for the past 5 months. He underwent a partial gastrectomy for gastric cancer 10 years ago. His
temperature is 37.1

Vitamin B12

Riluzole

Interferon beta therapy

Corticosteroids

12. A 27-year-old woman comes to the emergency department because of progressive numbness and weakness in her left arm
and left leg for 2 days. During this period, she has also had urinary urgency and incontinence. Three months ago, she had blurry
vision, difficulty distinguishing colors, and headache for one week, all of which have since resolved. Her temperature is 37

Dimethyl fumarate therapy

Interferon beta therapy

Administer IV methylprednisolone

Plasmapheresis

13. A 67-year-old man is brought to the physician by his daughter because he frequently misplaces his personal belongings and
becomes easily confused. His daughter mentions that his symptoms have progressively worsened for the past one year. On
mental status examination, he is oriented to person, place, and time. He vividly recalls memories from his childhood but can
only recall one of three objects presented to him after 5 minutes. His affect is normal. This patient's symptoms are most likely
caused by damage to which of the following?

Substantia nigra

Ventral posterolateral nucleus

Nucleus accumbens
 Hippocampus

14. A 63-year-old man comes to the physician for blurry vision and increased difficulty walking over the past month. He feels
very fatigued after watering his garden but feels better after taking a nap. He has not had any recent illness. He has smoked one
pack of cigarettes daily for 35 years. Examination shows drooping of the upper eyelids bilaterally and diminished motor strength
in the upper extremities. Sensation to light touch and deep tendon reflexes are intact. An x-ray of the chest shows low lung
volumes bilaterally. A drug with which of the following mechanisms of action is most appropriate for this patient?

Inhibition of muscarinic ACh receptor

Regeneration of acetylcholinesterase

Stimulation of D2 receptors

Inhibition of acetylcholinesterase

15. A 73-year-old woman is brought to the physician by her son because of increasing forgetfulness over the past 2 years.
Initially, she used to misplace keys and forget her dog's name or her phone number. Now, she often forgets about what she has
seen on television or read about the day before. She used to go for a walk every morning but stopped one month ago after she
became lost on her way back home. Her son has prevented her from cooking because she has had episodes of leaving the gas
stove oven on after cooking a meal. She becomes agitated when asked questions directly but is unconcerned when her son
reports her history and says he is overprotective of her. She has hypertension, coronary artery disease, and
hypercholesterolemia. Current medications include aspirin, enalapril, carvedilol, and atorvastatin. She is alert and oriented to
place and person but not to time. Vital signs are within normal limits. Short- and long-term memory deficits are present. Her
speech rhythm is normal but is frequently interrupted as she thinks of words to frame her sentences. She makes multiple errors
while performing serial sevens. Her clock drawing is impaired and she draws 14 numbers. Which of the following is the most
likely diagnosis?

Lewy body dementia

Vascular dementia

Creutzfeld-Jakob disease

Alzheimer disease

16. A 67-year-old man comes to the physician because of a worsening tremor that began 1 year ago. The tremor affects his left
hand and improves when he uses his hand to complete a task. He also reports feeling stiffer throughout the day, and he has
fallen twice in the past year. He has not noticed any changes in his cognition or mood. He has not had difficulty sleeping, but his
wife says that he would kick and punch while dreaming for almost a decade. His mother has Alzheimer disease. He drinks two
cans of beer daily. He takes no medications. He appears well-nourished. Vital signs are within normal limits. The patient
maintains a blank stare throughout the visit. Further evaluation is most likely to show which of the following?

Extensor plantar response

Cog-wheel rigidity on the left

Choreiform movements

No abnormalities

17. A 24-year-old medical student was studying late at night for an examination. As he looked at his textbook, he realized that
his left arm and left leg were numb. He dismissed the complaint, recalling that 6 or 7 months ago he had similar symptoms. He
rose from his desk and noticed that he had poor balance. He queried whether his vision was blurred, and remembered that he
had some blurred vision approximately 1 to 2 years earlier, but that this resolved. He had not seen a physician for any of these
previous symptoms. He went to bed and decided that he would seek medical consultation the next day.
 Amyotrophic lateral sclerosis

Multiple sclerosis

Myasthenia gravis

Ischemic Stroke

18. A critical difference between myogenic processes and disorders of the neuromuscular junction is:

The finding of fatigability with improvement after rest in neuro- muscular junction transmission disorders

Weakness of the ocular muscles only in neuromuscular junction transmission disorders

Myogenic findings on EMG

Elevated CPK in neuromuscular junction transmission disorders

19. A 32-year-old woman comes to the physician because of a 3-month history of recurrent headaches and nausea. The
headaches occur a few times a month and alternately affect the right or left side. The headaches are exacerbated by loud
sounds or bright light. She is in graduate school and has been under a lot of stress recently. She does not smoke or drink
alcohol but does drink 2

Cluster headache

Migraine headache

Tension headache

Medication overuse headache

20. A 35-year-old man is diagnosed with a seizure disorder. There is no history of trauma or medical condition. What is the most
common type of seizure in adults with epilepsy?

Absence seizures

Complex partial seizures

Grand mal seizures

Todd paralysis

21. A 22-year-old man is brought to the emergency department 25 minutes after an episode of violent jerky movements of his
arms and legs. He has no recollection of the episode. The episode lasted for 3

Generalized nonmotor seizure

Complex partial seizure

Status epilepticus

Generalized tonic-clonic seizure

22. A 35-year-old woman comes to the physician because of blurred vision for the past 2 months. During this period, she has
also had difficulty chewing and swallowing. She reports that her symptoms worsen throughout the day and improve with rest.
There is no personal or family history of serious illness. The patient works as a teacher and has had a great deal of stress lately.
She does not smoke and drinks a glass of wine occasionally. She takes no medications. Her temperature is 37.0

Plasmapheresis

MRI of the Brain

CT scan of the chest

Serum ACTH and CRH levels

23. A 64-year-old male comes to a neurologist with an 11-month history of pro- gressive weakness. He first noticed weakness
of his right hand with difficulty holding onto things. This progressed to right shoulder and upper arm weak- ness, with difficulty
raising his arm above his head or carrying things. The patient

Amyotrophic lateral sclerosis

Multiple sclerosis

Myasthenia gravis

Ischemic Stroke

24. A 24-year-old woman in graduate school comes to the physician for recurrent headaches. The headaches are unilateral,
throbbing, and usually preceded by blurring of vision. The symptoms last between 12 and 48 hours and are only relieved by lying
down in a dark room. She has approximately two headaches per month and has missed several days of class because of the
symptoms. Physical examination is unremarkable. The patient is prescribed an abortive therapy that acts by inducing cerebral
vasoconstriction. Which of the following is the most likely diagnosis?

Tension type headache

Migraine headache

Cluster headache

Medication overuse headache

25. Which of the following clinical features is associated with ALS?

Sensory loss on face

Resting tremor of the hands

Slurred speech

Loss of position sense of the toes

26. A 40-year-old woman comes into the physician

Initiate beta-blocker

Substitute aspirin for acetaminophen (Tylenol)

CT imaging of the head

Psychiatric evaluation
27. A 54-year-old man comes to the physician for the evaluation of difficulty swallowing solid food and liquids for 1 month.
During the past 5 months, he has also had increased weakness of his hands and legs. He sails regularly and is unable to hold
the ropes as tightly as before. Ten years ago, he was involved in a motor vehicle collision. Examination shows atrophy of the
tongue. Muscle strength is decreased in the right upper and lower extremities. There is muscle stiffness in the left lower
extremity. Deep tendon reflexes are 1+ in the right upper and lower extremities, 3+ in the left upper extremity, and 4+ in the left
lower extremity. Plantar reflex shows an extensor response on the left foot. Sensation to light touch, pinprick, and vibration is
intact. Which of the following is the most likely diagnosis?

Myasthenia gravis

Amyotrophic lateral sclerosis

Subacute combined degeneration of spinal cord

Multiple Sclerosis

28. A 33-year-old man comes to the emergency department because of repeated episodes of severe headache for the past 3
days. He is currently having his 2nd episode of the day. He usually has his first episode in the mornings. The pain is severe and
localized to his right forehead and right eye. He had similar symptoms last summer. He works as an analyst for a large hedge
fund management company and spends the majority of his time at the computer. He has been under a lot of stress because of
overdue paperwork. He also has chronic shoulder pain. He has been using indomethacin every 6 hours for the past 3 days but
has had no pain relief. He has smoked one pack of cigarettes daily for 15 years. He appears restless. Vital signs are within
normal limits. Physical examination shows drooping of the right eyelid, tearing of the right eye, and rhinorrhea. The right pupil is
2 mm and the left pupil is 4 mm. There is localized tenderness to his right supraspinatus muscle. The remainder of the
examination shows no abnormalities. Which of the following is the most likely diagnosis?

Trigeminal neuralgia

Migraine headache

Cluster headache

Medication overuse headache

29. A 21-year-old college student studying for final examinations com- plains of recurrent right temple pain, preceded by
flashing lights, and followed by nausea lasting 3

Subarachnoid headache

Post-LP headache

Migraine with aura

Migraine without aura

30. A 34-year-old woman is brought to the emergency department because of a 3-hour history of weakness, agitation, and
slurred speech. She speaks slowly with frequent breaks and has difficulty keeping her eyes open. Over the past three days, she
has had a sore throat, runny nose, and low-grade fever. She says her eyes and tongue have been

Amyotrophic lateral sclerosis

Multiple sclerosis

Myasthenia gravis

Ischemic Stroke
31. A 28-year-old man comes to the emergency department because of an excruciating headache that started 30 minutes ago.
The pain is located around the right eye and it awoke him from sleep. Over the past two weeks, he has had similar headaches
around the same time of the day, and he reports pacing around restlessly during these episodes. Physical examination shows
conjunctival injection and tearing of the right eye. In addition to supplemental oxygen therapy, administration of which of the
following drugs is most likely to provide acute relief in this patient?

Indomethacin

Sumatriptan

Carbamazepine

Amitriptyline

32. A 28-year-old woman comes to the physician because of a 4-hour history of headache and neck stiffness. She describes the
headache as a

Tension type headache

Migraine headache

Cluster headache

Medication overuse headache

33. A 33-year-old woman comes to the physician because of vision impairment in her right eye for the past 2 weeks. During this
period, she was unable to distinguish colors with her right eye. She also reports pain with eye movement. She has no double
vision. She occasionally has headaches that are relieved with ibuprofen. One year ago, she had a similar episode that affected
her left eye and resolved spontaneously. She has no history of serious illness. She works at a library and enjoys reading, even in
poor lighting conditions. Her vital signs are within normal limits. The pupils are equal, round, and reactive to light and
accommodation. Without correction, visual acuity is 20/50 in the left eye, and 20/100 in the right eye. With spectacles, the
visual acuity is 20/20 in the left eye and 20/100 in the right eye. Slit-lamp examination shows no abnormalities. A CT scan of
the head shows no abnormalities. Which of the following is the most likely diagnosis?

Open-angle glaucoma

Angle-closure glaucoma

Macular degeneration

Optic neuritis

34. A 28-year-old woman comes to the physician because of a 4-hour history of headache and neck stiffness. She describes the
headache as a

Carbamazepine therapy

Sumatriptan therapy

Ibuprofen therapy

Corticosteroids

35. A 24-year-old man is brought to the emergency department because of violent jerky movements of his arms and legs that
began 30 minutes ago. His father reports that the patient has a history of epilepsy. He is not responsive. Physical examination
shows alternating tonic jerks and clonic episodes. There is blood in the mouth. What is most likely diagnosis?
 Primary generalized epilepsy with tonic-clonic seizure

Complex partial seizure

Juvenile myoclonic epilepsy

Status epilepticus

36. A 72-year-old man comes to the physician with his son for a follow-up examination. The son reports that his father's mental
status has declined since the previous visit when he was diagnosed with Alzheimer dementia. The patient often begins tasks
and forgets what he was doing. He has increased trouble remembering events that occurred the day before and sometimes
forgets names of common household objects. He has hypertension and hyperlipidemia. His current medications include
lisinopril, hydrochlorothiazide, atorvastatin, and donepezil. He is confused and oriented only to person. He is unable to count
serial sevens backward from 100. He is able to register 3 items but unable to recall them 5 minutes later. Which of the following
is the most appropriate pharmacotherapy?

Risperidone

Ginkgo biloba

Memantine

37. A 61-year-old woman with a long history of type 2 diabetes is admit- ted to the hospital because of poorly controlled
disease. During her hospitalization she develops continuous tonic movements of her right arm and hand. A serum glucose is
measured as >600 mg/dL. Which of the following is the most appropriate step in management?

Noncontrast CT brain scan

Intravenous (IV) administration of lorazepam

Insulin drip and frequent serum glucose monitoring

Securing the airway

38. A 67-year-old man comes to the physician because of a worsening tremor that began 1 year ago. The tremor affects his left
hand and improves when he uses his hand to complete a task. He also reports feeling stiffer throughout the day, and he has
fallen twice in the past year. He has not noticed any changes in his cognition or mood. He has not had difficulty sleeping, but his
wife says that he would kick and punch while dreaming for almost a decade. His mother has Alzheimer disease. He drinks two
cans of beer daily. He takes no medications. He appears well-nourished. Vital signs are within normal limits. The patient
maintains a blank stare throughout the visit. Further evaluation is most likely to show which of the following?

Extensor plantar response

Cog-wheel rigidity on the left

Choreiform movements

No abnormalities

39. A 41-year-old man with multiple sclerosis comes to the physician for a follow-up examination. After evaluation, the
physician recommends the administration of baclofen to the patient. This drug is most likely to improve which of the following
symptoms?

Paresthesias

Spasticity
 Urinary incontinence

Urinary retention

40. A 33-year-old man is noted to have exacerbations of weakness. He is diagnosed with MS. Which of the following findings is
consistent with the diagnosis?

The diagnosis of MS is based on clinical lesions separated by time and space

Oligo bands in the CSF are specific for multiple sclerosis

Steroids are effective in improving the course of disease

This is a genetic disorder well characterized on chromosome 11

41. A 72-year-old man comes to the physician with his son for a follow-up examination. The son reports that his father's mental
status has declined since the previous visit when he was diagnosed with Alzheimer dementia. The patient often begins tasks
and forgets what he was doing. He has increased trouble remembering events that occurred the day before and sometimes
forgets names of common household objects. He has hypertension and hyperlipidemia. His current medications include
lisinopril, hydrochlorothiazide, atorvastatin, and donepezil. He is confused and oriented only to person. He is unable to count
serial sevens backward from 100. He is able to register 3 items but unable to recall them 5 minutes later. Which of the following
is the most appropriate pharmacotherapy?

Risperidone

Ginkgo biloba

Citalopram

Memantine

42. 28-year-old woman comes to the physician because of a 4-hour history of headache and neck stiffness. She describes the
headache as a

Tension type headache

Migraine headache

Cluster headache

Medication overuse headache

43. A 27-year-old woman comes to the emergency department because of progressive numbness and weakness in her left arm
and left leg for 2 days. During this period, she has also had urinary urgency and incontinence. Three months ago, she had blurry
vision, difficulty distinguishing colors, and headache for one week, all of which have since resolved. Her temperature is 37

Myasthenia gravis

Multiple sclerosis

Amyotrophic lateral sclerosis

Viral meningitis

44. A 22-year-old man is brought to the emergency department 25 minutes after an episode of violent jerky movements of his
arms and legs. He has no recollection of the episode. The episode lasted for 3

Generalized tonic-clonic seizure

Complex partial seizure

Status epilepticus

Generalized nonmotor seizure

45. A 28-year-old woman comes to the physician because of increasingly frequent episodes of double vision for 2 days. She
was seen in the emergency department for an episode of imbalance and decreased sensation in her right arm 3 months ago.
Examination shows impaired adduction of the right eye with left lateral gaze but normal convergence of both eyes. Deep tendon
reflexes are 4+ in all extremities. The Romberg test is positive. An MRI of the brain shows hyperintense oval plaques in the
periventricular region and a plaque in the midbrain on T2-weighted images. Microscopic examination of material from the
midbrain plaque would most likely show which of the following?

Eosinophilic intracytoplasmic inclusion bodies

Loss of axons and atrophy of oligodendrocytes

Extracellular deposits of amyloid peptides

Demyelination with partial preservation of axons

46. A 62-year-old woman is brought to the physician because of 6 months of progressive weakness in her arms and legs. During
this time, she has also had difficulty swallowing and holding her head up. Examination shows pooling of oral secretions. Muscle
strength and tone are decreased in the upper extremities. Deep tendon reflexes are 1+ in the right upper and lower extremities,
3+ in the left upper extremity, and 4+ in the left lower extremity. Sensation to light touch, pinprick, and vibration are intact.
Which of the following is the most likely diagnosis?

Amyotrophic lateral sclerosis

Guillain-Barre syndrome

Multiple Sclerosis

Myasthenia gravis

47. A 9-year-old boy is diagnosed with absence seizures. Which of the fol- lowing would most likely best describes his seizure
episodes?

Tremulousness of the right arm in the absence of other movement disorder

Momentary lapses in awareness, accompanied by motionless staring and cessation of any ongoing activity

Alternate flexion and extension and rigidity of the arms and legs

Sudden loss of posture and falling unconscious to the floor

48. A 22-year-old man is brought to the emergency department 25 minutes after an episode of violent jerky movements of his
arms and legs. He has no recollection of the episode. The episode lasted for 3

MRI

EMG
 EEG

Lumbar puncture

49. A 45-year-old man with history of embolic stroke 1 year ago presents with a generalized seizure. Which of the following is
the most likely best choice?

Seizures are likely to continue to occur in this individual

Embolic strokes require a patent foramen ovale

This patient likely has a partial seizure disorder

This patient likely has diabetes

Test System 2022